There are a variety of existing medical record systems that range from pen and paper systems to electronic medical record systems. These systems have been developed for use within a particular doctor's office or other medical facility, but have not been adapted for use by first responders or far forward casualty response due to the inherent infrastructure requirements and primary focus of those systems, which generally has been recording of doctor's notes and/or ordering prescriptions.
The U.S. Army Medical Research and Material Command (USAMRMC) Telemedicine & Advanced Technology Research Center (TATRC) at Fort Detrick, Md., has been and is continuing to investigate utilization of commercially available, “off-the-shelf” (COTS) hand-held wireless devices for use in routine medical care in military environments. The objective has been and continues to be to improve military health care by improving medical decision making and reducing errors beginning at the point of care. Application of wireless information technologies to medical informatics and telemedicine applications at the point of care can achieve these objectives by 1) improving accuracy and efficiency of point of care data entry, thereby improving the quality of the medical records used in medical decision making and 2) providing immediate access at the point of care to key information and knowledge needed by military health care providers to make informed medical decisions. A system that satisfies these objectives is further needed to facilitate improved point-of-care diagnostic, epidemiology collection and bio-informatics tool. Specific areas identified to improve and satisfy these objectives are medical readiness, medical assessments and treatment, medical reporting and documentation, medical skills training, medical supply, and security of medical information. In each area information was gathered through research, practical experience, interviews, and literature searches.
Medical readiness was analyzed by conducting a review of the processing of 22,000 soldiers through a readiness site. The U.S. Military medically processes soldiers prior to every deployment whether training or real world in order to maintain a high state of medical readiness. The process is referred to as a Preparation for Oversees Movement (POM) or as the Soldiers Readiness Program (SRP). This process is accomplished by manually screening the outpatient health records, verification of required information and filling in a form on every individual to establish a field medical record.
This process currently requires many man hours of preparation and the medical part of the POM process currently takes an average of 6-8 hours using 4-6 medical screeners to medically process a Battalion sized element of approximately 500 personnel. (The times do not include the return visits for Physical completion). During the POM process individual medical deficiencies are identified such as missing immunizations, allergy alert tags when required, outdated physicals, glasses, inserts if required and any current medications. In addition to any health related issues and physical limitations that could render the soldiers non-deployable. Once identified efforts are made to correct these deficiencies during the screening process. During the time of this study both active military and reserve military components where processed.
The units observed were at varying levels of medical readiness and deficiencies could have easily been identified if the readiness information was in computerized format. The soldiers who were deployable could accurately and efficiently be identified as not requiring processing through the readiness site. This would greatly reduce the time it takes to medically process personnel from 6-8 hours easily to 3-4 hours. In addition if this information was made available electronically it would allow commanders immediate access to readiness information that would be previously unobtainable without going through the screening process.
An analysis of the medical assessment and treatment process was performed. In combat arms units and troop medical clinics there are three environments for medical assessment and treatment that are identifiable for combat medics and first responders in the U.S. Army. The first environment is the home station where the soldiers are in a garrison environment at their unit of assignment and the medical screening process takes place by combat medics either in the company area, the battalion aid station, or the troop medical clinic. At the home station, medics have access to the Soldiers Outpatient Medical Records and authorized sick call medications and supplies to be used within their scope that they normally do not have the capacity to carry with them while they are in field environments. The Medics are responsible for primary triage and treatment of soldiers for sick call using the HSC PAM 40-7-21 Ambulatory Patient Care, Algorithm Directed Troop Medical Care or by practical knowledge obtained while working in a health clinic with physicians assistants or physicians. The patient encounter and collection of information begins with the medical screeners and continues throughout the patients screening process. Once screened the soldiers are either given medications, treatments or sent to the physician or physicians assistant for further evaluation and treatment. If the patients received treatment by a medic, a physician or physicians assistant will verify the treatment and sign off on the encounter.
The next environment is the training environment, which is when units or elements of the unit are deployed either to a local field training environment or tactical training environments. The medics are responsible for primary triage and treatment of soldiers for battle injuries, non-battle injuries, disease, psychological and sick call. The combat medics that were interviewed and assigned to the combat arms unit that served as the base of this study received minimal training in these areas and were generally not well trained due to the unit's requirement for the medics to maintain a high level of readiness of their assigned vehicles thus decreasing the amount of training required for medics to maintain a high level of medical proficiencies.
In the study group, there were eight medics with two assigned to each company, one of the medics per pair of companies was a senior medic and the other three were combat medics. In all but two instances the medics were left to their own devices when it came to the initial triage and treatments of soldiers in the training environments. In the other two instances the soldiers were evacuated immediately without the required field medical cards. In the rest of the cases reviewed soldiers received inadequate medical treatment and were returned to duty until the unit or element returned to home station ranging from 24 hours up to 30 days. Upon return to home station, soldiers were then re-screened then treated as appropriate. In addition in all 40 of the cases that were screened for sick call in the field environment none of the required information was collected at the initial point of care nor were the medical supplies (Class VIII) accounted for in these treatments. During each of the training exercises soldiers were each issued MILES casualty cards and when the soldier becomes injured through the training simulation he reads the MILES cards and presents the medic with the symptoms listed on the cards. The medics are then responsible for the triage and treatment of the soldiers as necessary and as appropriate. This encounter is then documented on a Department of Defense 1380 Field Medical Card. Approximately 820 personnel from each company became casualties depending on the scenarios. By the time the casualties reached the Level I Battalion Aid station approximately 50% of the casualties had varying levels of treatment and approximately 10% had the required DD form 1380 and 50% of those had the required information filled in on the Field Medical Card. At the battalion aid station the medics and providers initiated the missing field medical cards and filled in the missing treatments but in most cases lacked the necessary information to complete the initial encounter information due to lack of knowledge of the circumstances surrounding the injuries.
The last environment studied was the deployed state, which is when units are deployed to an operational environment either in the United States or in foreign countries. This part of the study was conducted using practical experience and interviews and review of medical information. In this environment, the medics are responsible for primary triage and treatment of soldiers for battle injuries, non-battle injuries, disease, psychological and sick call. The medics have limited resources and are generally left to their own devices to maintain unit medical readiness and treatment during operations other than war such as humanitarian missions and peace keeping operations. They are also required to conduct triage and treatment of soldiers during high intensity conflicts and acts of war. During these deployments medics were provided little to no communications at all. Of the three cases reviewed: one soldier received combat related injuries, one soldier was evacuated due to stress related issues, and the third soldier had a dermatological condition that was treated and returned to duty. Of the three cases the soldier that had combat related injuries received lifesaving treatment and was evacuated, the encounter was documented on a small piece of paper which upon review of the health record showed that is was lost and the soldier had to be re-screened and the treatments had to be estimated. In case number two, the soldier was evacuated and the required encounter was not documented prior to evacuation. In the third case, the soldier was treated and returned to duty and the required information was not documented and a follow-up was scheduled and the initial treatment was re-initiated and documented at that time.
The required training to maintain medical skills proficiency is either not being conducted or is inadequate to provide the required skill sets for the combat medics. The initial training provided to combat medics is insufficient to prepare them to conduct sick call at the unit level and in field environments. The required information is not being adequately collected or documented at the point of care and point of injury possibly due to insufficient emphasis being put on the requirement or due to the time it takes to document an encounter. Forty medics were provided various combat injury scenarios and had them fill in the required elements on a field medical card. It took the 40 medics an average of 3-5 minutes to fill in the initial encounter. This could have a negative impact on the required lifesaving treatment of combat injuries especially during a mass casualty scenario. The lack of documentation of the treatment at the initial point of treatment could also cause unnecessary administration of additional medications thus causing clinical errors after initial triage. Providers would be more likely to capture this information at the point of care/point of injury if there could be an impact on the time it takes to document the encounter on the field medical card. During both the training and deployed environments, medics had little to no communications available to them to request resupply and had to rely on a supply request written on notepads and in some case did not get re-supplied until returning to their respective home station. If medics were provided organic communications they could have immediate access to more experienced providers and could then provide better medical care in the deployed environment well as provide immediate information for medical reporting which is important for not only clinical treatment, command and control but also resupply of class VIII medical supplies.
An analysis of medical reporting and documentation was conducted through practical experience, review of outpatient health records, interviews and review of literature. On average, 25,000 pages of documents and forms pour into the DoD Medical Records every day. Requests for service, such as sick call, are a daily occurrence; efforts to provide that service promptly were once a struggle. Medical reporting is currently accomplished by collecting log sheets and collating them from the referring units and questionnaires completed by both referring and consulting doctors. See “Presidential Advisory Committee on Gulf War Veterans' Illness Final Report, 1996”.
A review of a set of 5000 outpatient health records for active duty soldiers provided a set of 492 records that were for combat related injuries. Of those 492 records there was just one Department of Defense Form 1380 Field Medical Card present, which indicates that information was getting lost or not captured at all and in accordance with AR (Army Regulation) 40-66, Medical Record and Quality Assurance Administration that requires the DD form 1380 and all health care information collected is required to be maintained in the health care records. The Medical Records Section and the Personnel Administration Division Officer responsible for these records indicated that the DD form 1380 is not required to be maintained in the outpatient health record and that it is usually destroyed.
Due to insufficient training of medical records personnel and/or lack of information collected at the point of care/point of injury medical information is lost, not captured or destroyed. If there were a means by which to capture this information in a computerized format there would be 1) an increase in the efficacy of the information, 2) tracking capability for epidemiological information, and 3) immediate access to medical information for command and control based on the computerized clinical encounters.
The next part of the analysis was conducted by practical experience, observation and interviews related to the skills training of the medics. In combat maneuver battalions, the qualifications of the combat medics vary depending on educational background, experience and motivation. Medics are provided initial training for responding to combat related injuries and rudimentary clinical documentation. It is generally left up to the unit of assignment to provide further skills training for soldiers. As the soldiers go up in rank they are sent to more advanced medical training or Special Forces medical training. The more skilled medics, physicians and physicians assistant are responsible to train the lesser skilled medics during scheduled training times and through practical experience. Of the combat medics observed and interviewed, they typically lacked the sufficient skills to respond to real world injuries and sick call screening, unless they had been assigned to a Medical Center or health clinic during their early career. There were extreme skills deficiencies of the medics that were directly assigned to combat arms units from their initial training.
The focus for training in the combat arms units were on vehicle maintenance and it was expected that medics were highly trained prior to being assigned to the unit. In addition medics received training one day per week on medical skills and/or training on how to pass the Expert Field Medical Badge training. This training was complimentary to training medics to a high level of proficiency in field medicine for combat injuries, but this training lacked severely in training medics on how to provide treatment for sick call or non-combat related injuries. One way to address this would be to have a skills trainer or training device that could help to facilitate interactive training for combat medics and Special Forces medics.
The next part of the analysis was accomplished through practical experience, observation and literature research and related to medical supply. When in a training or deployed environment, Class VIII medical supplies are generally ordered after a manual inventory of supplies is conducted, then the supplies are ordered when communications become available or through sending supply request on notepads. Of all of the medics interviewed they were not documenting the medical supplies that were used for training, deployments or for sick call in field environments. At the battalion aid station supplies were inventoried and reordered monthly or as needed for sick call. The medical supplies in the combat load were inventoried either annually or during a major deployment as necessary.
During both the training and deployed environments, medics had little to no communications available to them to request resupply and had to rely on supply requests written on notepads and in some case did not get re-supplied until returning to their home station. This form of resupply leads to a decrease in the combat readiness of the medics limiting their ability to continue to provide medical treatment to the soldiers at the initial point-of-care.
This last part of the analysis was accomplished through practical experience and observation and related to the security of the medical information. The security of medical information for the combat medic is limited to the physical security of health care information by the combat medic.
Most combat medics carry a leader's book which contains some soldier information, medical information such as current medications, allergies and possibly some medical history. Medics also are required to capture information on Field Medical Cards DD 1380, when they capture the information they remove an onion skin (protective Paper) and maintain a copy of each encounter in the Field Medical Card Book. Each encounter not only contains medical information but also the soldier's demographics and unit information. At the battalion aid station, they maintain the outpatient health records in filing cabinets that are maintained by medics and assigned personnel.
The security of medical information at the point of care at the level of the combat medic is inadequate to today's emerging health care security standards and could provide potentially vital tactical information to hostile forces if lost or if the medic is captured. The current field medical cards and accompanying book that maintains the copies of the field medical cards can not easily be torn up, nor can they be easily burned or destroyed. If the information is in computerized format on a handheld device the information could be made more secure and even easily erased to preclude the information getting into the hands of anyone but the intended provider.
On the backdrop of the above analysis, there is a Presidential Review Directive 5 that mandates development of a standardized, integrated and seamless system of medical command and control for the military medical community within Global Command and Control System (GCCS) to include an individually carried device.
The Department of Defense is currently funding the Composite Health Care System II (CHCS II) program intended to produce a clinical information and medical information management support system for military peacetime health care facilities as a follow-on to the current CHCS (I) system which currently provides medical administrative information management, ancillary services support and order entry for both inpatient and outpatient care in most fixed DOD health care facilities. While CHCS II is intended as a point of care system to support most health care provider information processing needs, it is limited by placement of desktop PCs or location of laptop PC LAN “plug-in” locations. To the best of the present inventor's knowledge, a truly portable, pocket-sized PC tool is not being provided by the CHCS II system.
DOD (HA) has also designated a program manager for deployable military health care information processing systems development. The Theater Medical Information Program (TMIP) is charged with identifying requirements and developing deployable medical information systems for the DOD. As yet the TMIP has not fielded a point of encounter clinical information system for deployable medical units. A PC based version of CHCS I has been used within some deployable military hospitals on an experimental basis. Each service is also charged with producing service-specific TMIP applications for far-forward applications within service specific areas of support and for adapting its deployable computer hardware or acquiring service supportable hardware to support both service specific and joint TMIP applications.
The Air Force TMIP application is called “Care in the Air”. This program is currently testing PSC-5 UHF SATCOM radios to support medical data transmission from Air Force aircraft; this UHF radio system already exists on Air Force aircraft for support of Army ground missions. Air Force medics, testing demand access to aircraft data, must be able to access data “seamlessly” from a “netcentric” database and be able to pull out demographic data, identify the location and point of injury, and initial treatment provided. Even though this mission is one of that requires significant individual provider mobility, the Air Force is still using laptop PCs and bubble jet printers in conjunction with backpack ground terminal radios. No handheld PC point of care system is currently included in the Care in the Air program even though such a system would help solve mobility issues stemming from the cumbersome nature of the systems currently being tested.
The Army deployable medical information systems program is called Military Communications for Combat Care (MC4). MC4 is primarily concerned with acquiring the hardware and communications systems to support Army medical command and control and the DOD TMIP program. However, MC4, has identified the need for a handheld notebook computer or personal data assistant for first responder Army medics. To test that concept the MC4 has spent significant resources developing an inflexible Windows CE medical encounter data recording application that is so proprietary and so rigid in its design that it cannot be readily expanded or adapted for use by military health care providers beyond first responder medics without significant redesign and software reengineering. What is really needed at this level is a system that can be configured or tailored by users at each level of the military health care continuum to meet situation specific information processing needs without retraining.
The Navy version of the Theater Medical Information Program, TMIP Maritime, is also pursuing a parallel path toward a deployable medical informatics support system. The Navy has worked on deployable computerized medical monitoring and patient registration systems, “wireless” data gathering from a Navy version of the “Personal Information Carrier” medical data tag, and various medical image acquisition and transmission systems. None of these projects have produced a versatile handheld personal data assistant capable of meeting all of the point of encounter medical information needs of providers at multiple levels of the military health care system.
The U.S. Army Medical Department Center and School (AMEDD C&S) has developed an approved Tables of Organization and Equipment (TOE) for Medical Reengineering Initiative (MRI) Combat Support Hospitals and for the Medical Detachment (Telemedicine), a specialized unit intended to provide immediate short term medical command and control communications and telemedicine support for an Army TOE Medical Brigade. These TOES include requirements for organic broadband multi-mode (voice, data, video) telecommunications switches for each MRI TOE Combat Support Hospital and satellite earth stations for each of the 6 deployable teams which make up a Medical Detachment (Telemedicine). These teams are intended to bridge the gap between the dynamic modern communications needed for highly deployable, state of the art military health support and the military bandwidth relegated to and outdated communications systems available to deployable U.S. military health care organizations. While these teams are intended to provide some highly mobile telemedicine and medical informatics capabilities to rapidly deploying medical units, the teams will not be equipped with the type or numbers of personal handheld systems required by first responders and forward deployed physicians for point of encounter medical information processing support.
The U.S. Army Medical Research and Material Command and the AMEDD C&S have collaborated since 1996 with the Signal Battle Command Battle Lab Gordon (BCBLG) to integrate telemedicine and satellite communications capabilities into the Army Warfighter Information Network-Proof of Concept (WIN-POC) mobile communications switch, as a platform for providing multi-user broadband medical command and control communications and telemedicine connectivity. This capability was successfully demonstrated in 1999 at the Joint Readiness Training Center (JRTC), Fort Polk. The medical WIN-POC is intended to provide sustained broadband communications from forward deployed areas and joint task force headquarters locations rearward to the Theater and National Military Command Headquarters and Military Health System Medical Centers worldwide. The WIN-POC has a deployable state-of-the-art Asynchronous Transfer Mode communications switch that is capable of receiving and transmitting voice, data and video simultaneously from multiple deployed sites using either military or commercial radio, wired, wireless or satellite communications. The WIN-POC can also be equipped with a local cellular or other wireless telephone switch to provide both local and long distance telephone service. Satellite connectivity through the WIN-POC using a Very Small Aperture Terminal (VSAT) satellite earth station was also demonstrated at the JRTC. This capability is intended for deployed medical facilities through area or direct support common user communications facilities that are part of the Army Warfighter Information Network-Terrestrial (WIN-T) concept.
The Joint Medical Operations-Telemedicine (JMO-T) Advanced Technology Demonstration (ACTD) conducted by the U.S. Pacific Command during the period FY1999-FY2002. The operational concepts of this ACTD were embodied in five interrelated pillars: Forward Health Care, Information Superiority, Net-Centric Communications, Theater Telemedicine Force Package, and Medical Mission Planning and Rehearsal. The ACTD explored the conceptual feasibility of leveraging emerging information technologies to support those operational concepts. The JMO-T ACTD attempted to provide satisfaction of critical Warfighter operational issues with the insertion of mature medical, telecommunications, and information technologies. Demonstration and evaluation used planned joint exercises as platforms to employ the target capabilities, collect and analyze performance data, and derive user acceptance conclusions. Technologies employed to achieve these advanced concepts included handheld data input devices, digitized medical equipment sets, mobile communication devices, and wireless technologies. The centerpiece of the ACTD was the deployable theater telemedicine force package, designed to provide early-in hardware, software, and communication capabilities for the collection and sharing of critical medical information from far forward on the battlefield. Digital medical imaging equipment; interoperable telemedicine teams; and computerized, interactive medical force planning and rehearsal tools are being leveraged to provide enhanced force medical protection under Joint Vision 2010 operational concepts. While the JMO-T ACID is leveraging many of the evolving DOD medical informatics and telemedicine tools described above, the demonstration manager has not yet identified a multi-application handheld tool for providing on-line two-way medical information support for first responders. A wireless, flexible and scalable personal data assistant that can be used by military health care providers at all levels of care from the foxhole to the medical center is the ideal tool to meet the JMO-T ACTD objective of providing useful medical informatics and telemedicine support for first responders across the spectrum of the military health care operations and continuum of support levels of care.
The Global Grid Telemedicine System (GGTS) concept which envisions leveraging emerging worldwide military and civilian communications and information processing networks to enable intelligent medical consultation routing and medical information processing is being considered as the “infosphere” architecture and communications “backbone” infrastructure on which to test the ACTD objectives described above. The U.S. Army Medical Research and Material Command and the U.S. Army 1108th Signal Brigade in conjunction with the JMO-T ACTD Demonstration Manager have developed a transition strategy for GGTS netcentric medical communications within the emerging Command Control Communications Computers Intelligence Surveillance and Reconnaissance (C4ISR) infrastructures. The strategy involves two research phases and an acquisition phase. Formulation of this strategy focused on identifying Government and Commercial off-the-shelf (GOTS and COTS) applications, that when combined with custom software while allowing for development consistent with the Defense Information Infrastructure Common Operating Environment (DII COE), can support the affordable development of GGTS. The JMO-T ACTD implementation of the GGTS offers an excellent opportunity to test the concept of a wireless medical enterprise in a way that insures extensive definition of the GGTS functions in collaboration with operational users.
Following the experiences with Agent Orange exposure during the Vietnam War and more recently from adverse health claims by some members deployed during the Persian Gulf War, health surveillance is becoming an essential occupational health tool for diversely deployed military troops facing myriad and often unknown environmental exposures and hazards. In response to the public outcry, Public Law 105-85 was instituted on Nov. 18, 1998, mandating the DoD to develop a deployment health surveillance system to detect and prevent health problems arising as a result of exposures during deployments and operations. Given the far-reaching concerns, associated fiscal costs, and perceptions of “cover-up” surrounding post-conflict illnesses among Gulf War veterans, it is not surprising that Congress provided legislative direction regarding military health surveillance and record keeping.
What is needed is proof of concept integration and application of commercial off-the-shelf (COTS) medical informatics, telemedicine, and wireless information technologies to (1) explore use of wireless networking in medical settings within deployable combat medics in the field, (2) test prototype systems that make use of Personal Digital Assistants (PDA) as point-of-care diagnostics, data collection, medical order entry, and knowledge acquisition tools in a wireless “net-centric” distributed computing environment, (3) web browser applications and the Internet to enable immediate access to distributed expertise and knowledge from diverse data and knowledge bases and expert medical consultants world-wide and 4) apply advanced technologies for data gathering and bi-directional transfer of vital information between the battlefield, theater operations, and home based fixed medical facilities. Models created will potentially enable an efficient and non-intrusive “behind the scenes” aggregation of data to be used for wide variety of purposes including, but not limited to, case-based medical equipment re-supply, staffing needs assessment, outcomes-based appraisals, and sundry patient/provider pattern analyses so critical in an era of managed care.